Elevated prevalence of multidrug-resistant gram-negative organisms in HIV positive men

Predicting Risk of Multidrug-Resistant Enterobacterales Infections Among People With HIV

Background

Medically vulnerable individuals are at increased risk of acquiring multidrug-resistant Enterobacterales (MDR-E) infections. People with HIV (PWH) experience a greater burden of comorbidities and may be more susceptible to MDR-E due to HIV-specific factors.

Methods

We performed an observational study of PWH participating in an HIV clinical cohort and engaged in care at a tertiary care center in the Southeastern United States from 2000 to 2018. We evaluated demographic and clinical predictors of MDR-E by estimating prevalence ratios (PRs) and employing machine learning classification algorithms. In addition, we created a predictive model to estimate risk of MDR-E among PWH using a machine learning approach.

Results

Among 4734 study participants, MDR-E was isolated from 1.6% (95% CI, 1.2%-2.1%). In unadjusted analyses, MDR-E was strongly associated with nadir CD4 cell count ≤200 cells/mm³ (PR, 4.0; 95% CI, 2.3-7.4), history of an AIDS-defining clinical condition (PR, 3.7; 95% CI, 2.3-6.2), and hospital admission in the prior 12 months (PR, 5.0; 95% CI, 3.2-7.9). With all variables included in machine learning algorithms, the most important clinical predictors of MDR-E were hospitalization, history of renal disease, history of an AIDS-defining clinical condition, CD4 cell count nadir ≤200 cells/mm³, and current CD4 cell count 201-500 cells/mm³. Female gender was the most important demographic predictor.

Conclusions

PWH are at risk for MDR-E infection due to HIV-specific factors, in addition to established risk factors. Early HIV diagnosis, linkage to care, and antiretroviral therapy to prevent immunosuppression, comorbidities, and coinfections protect against antimicrobial-resistant bacterial infections.

Antimicrobial-resistant Enterobacterales colonization in people with HIV

Background

People with HIV (PWH) may be at increased risk for MDR Enterobacterales (MDR-E) infection or colonization, relative to individuals without HIV, due to a greater burden of comorbidities as well as HIV-related intestinal inflammation and microbiota alterations.

Objectives

To characterize antibiotic susceptibility of enteric Enterobacterales and risk factors for antimicrobial-resistant bacterial infections in a sample of PWH attending routine clinic visits.

Methods

Participants provided self-administered rectal swabs and completed questionnaires regarding healthcare, travel and occupational exposures for the prior 12 months. Rectal samples were processed to identify Enterobacterales species, and susceptibility testing was performed.

Results

Among 82 participants, 110 Enterobacterales isolates were obtained. Non-susceptibility was common for penicillins, sulphonamides and first-generation cephalosporins. MDR-E was present in 20% of participants. HIV-related characteristics, including current or nadir CD4 cell count, viral suppression, or AIDS-defining clinical conditions, were not associated with MDR-E.

Conclusions

MDR-E colonization is common in this population of PWH. Further research evaluating risk factors for MDR-E in PWH may inform infection prevention approaches to better protect at-risk populations from these difficult-to-treat infections.

Evidence of sexual transmission of extended-spectrum β-lactamase-producing Enterobacterales: a cross-sectional and prospective study

BACKGROUND

Extended spectrum β-lactamase-producing Enterobacterales (ESBL-E) represent a major threat to public health. Little is known on their potential for sexual transmission.

METHODS

We recruited individuals at a sexually transmitted infection and HIV-outpatient clinic in Paris, France in whom we evaluated the prevalence of ESBL-E intestinal carriage and among those positive, the proportion with clearance 6 months thereafter. We compared carriage prevalence between groups using logistic regression adjusted for age, geographic origin, travel outside of Europe, and antibiotic use <6 months.

RESULTS

2157 individuals participated, of whom 226 (10.5%) were ESBL-E carriers. The proportion of ESBL-E carriers varied across sexual groups: HIV-negative men who have sex with men (MSM) on pre-exposure prophylaxis (PrEP), 16.3% (n=41/251); HIV-negative MSM not on PrEP, 9.7% (n=47/487); HIV-positive MSM, 12.2% (n=61/500); HIV-negative men who exclusively have sex with women, 10.0% (n=44/439); and HIV-negative women who have sex with men (WSM), 6.9% (n=33/480). After adjustment, ESBL-E prevalence was significantly higher in HIV-negative MSM on PrEP (p<0.001) and HIV-positive MSM (p=0.01) compared to WSM. Number of sexual partners <6 months was associated with ESBL-E carriage after adjustment (p=0.004). blaSHV-12-producing ESBL-E and E. coli Sequence Type 14 were observed only in MSM. Of 102 individuals with ESBL-E returning for testing, 26 (25%) had carriage at 6 months.

CONCLUSION

ESBL-E carriage is more frequent in MSM undergoing PrEP or living with HIV, and with increasing number of sexual partners. More research is warranted to understand the consequences of ESBL-E carriage in these populations and how transmission can be reduced.

OUP accepted manuscript

Objectives

The widespread intestinal carriage of ESBL-producing Escherichia coli (ESBL E. coli) among both patients and healthy individuals is alarming. However, the global prevalence and trend of this MDR bacterium in healthcare settings remains undetermined. To address this knowledge gap, we performed a comparative meta-analysis of the prevalence in community and healthcare settings.

Methods

Our systematic review included 133 articles published between 1 January 2000 and 22 April 2021 and indexed in PubMed, EMBASE or Google Scholar. A random-effects meta-analysis was performed to obtain the global pooled prevalence (community and healthcare settings). Subgroup meta-analyses were performed by grouping studies using the WHO regions and 5 year intervals of the study period.

Results

We found that 21.1% (95% CI, 19.1%–23.2%) of inpatients in healthcare settings and 17.6% (95% CI, 15.3%–19.8%) of healthy individuals worldwide carried ESBL E. coli in their intestine. The global carriage rate in healthcare settings increased 3-fold from 7% (95% CI, 3.7%–10.3%) in 2001–05 to 25.7% (95% CI, 19.5%–32.0%) in 2016–20, whereas in community settings it increased 10-fold from 2.6% (95% CI, 1.2%–4.0%) to 26.4% (95% CI, 17.0%–35.9%) over the same period.

Conclusions

The global and regional human intestinal ESBL E. coli carriage is increasing in both community and healthcare settings. Carriage rates were generally higher in healthcare than in community settings. Key relevant health organizations should perform surveillance and implement preventive measures to address the spread of ESBL E. coli in both settings.

Resistance in Enterobacterales is higher among people with HIV

BACKGROUND

Multidrug-resistant Enterobacterales (MDR-E) are important pathogens. People with human immunodeficiency virus (HIV) may be at greater risk for MDR-E infection given relatively high antibiotic exposure and burden of comorbidities.

METHODS

Analyses were conducted using data collected on 36,521 patients in a healthcare system in North Carolina, who had at least 1 clinical culture with growth of an Enterobacterales species from 2000-2018; 440 were people with HIV infection (PWH). We used generalized linear models to estimate prevalence ratios and differences contrasting patients with and without HIV for resistance to individual antibiotic classes, as well as MDR-E. We assessed trends in prevalence over time by calculating the 5-year moving average and fitting restricted cubic spline models.

RESULTS

The overall prevalence of MDR-E was higher among PWH (21.5% [95% CI: 18.2%-25.1%]) versus patients without HIV (16.5% [95% CI: 16.2%-16.9%], with an adjusted prevalence ratio of 1.38 (95% CI: 1.14-1.65). PWH had higher rates of antimicrobial resistance than patients without HIV for all antibiotic classes analyzed, including penicillins, penicillin/beta-lactamase inhibitor combinations, and sulfonamides. MDR-E prevalence was 3 to 10 percentage points higher among PWH than patients without HIV throughout the study period based on the 5-year moving average.

CONCLUSION

In a large clinical study population in the southeastern US from 2000-2018, the prevalence of antibacterial resistance among Enterobacterales was consistently higher among PWH than patients without HIV. These data highlight the importance of identifying and mitigating the factors contributing to antimicrobial resistance in PWH, given the potential clinical consequences of these resistant pathogens.

[Antibacterial Susceptibility Patterns of Bloodstream Isolates in 74 HIV-Infected Patients Hospitalized at the Clinic of Infectious and Tropical Diseases of Fann University Hospital, Dakar from 2013 to 2016]

Introduction

Bacteremia is associated with high lethality in HIV-infected patients. The widespread use of cotrimoxazole prophylaxis and misuse of antibiotics promote antibacterial resistance. Only few studies have considered this issue in HIV-infected patients. Thus, the objective of this study was to describe the etiology and antibacterial susceptibility patterns of bloodstream isolates in patient living with HIV.

Material and methods

This is a retrospective cross-sectional and descriptive study conducted at the clinic of Infectious and Tropical Diseases of Fann university hospital from March 2013 to December 2016. Data were collected from patients' files according to a pre-establish survey form made of demographic, clinical, bacteriological and biological parameters.

Results

Seventy-four cases of bacteremia were registered, 51.4% of which in women. Participants' median age was 45 years old [18-73 years old] and average CD4 count 83.3 cells/μl. The most commonly isolated bacteria were coagulase negative staphylococci (14%) followed by Escherichia coli (10%) and Klebsiella pneumoniae (10%). Rates of methicillin resistance for coagulase negative staphylococci and Staphylococcus aureus were 35.7% (5/14) and 22% (2/9), respectively. The most frequent ESBL producing germs were Escherichia coli 50% (5/10), Klebsiella pneumoniae 40% (4/10) and Enterobacter sp 25% (2/8). Pseudomonas sp were the most (22.2%) germs resistant to carbapenems.

Conclusion

The result of this study advocates the need for ongoing surveillance of antibacterial resistance in HIV-infected patients and empirical antibiotic therapy based on surveillance data.

High carriage of ESBL-producing Enterobacteriaceae associated with sexual activity among men who have sex with men

BACKGROUND

Extended-spectrum β-lactamase Enterobacteriaceae (ESBL-E) may be sexually transmitted. Men who have sex with men (MSM) have different sexual behaviour than the general population, and thus may be at risk for ESBL-E carriage. This study determined the prevalence of ESBL-E carriage and its association with sexual behaviour among MSM in Amsterdam, The Netherlands.

MATERIALS AND METHODS

In total, 583 HIV-positive and HIV-negative MSM from the Amsterdam Cohort Study were screened for rectal ESBL-E carriage between April and December 2018. Participants completed a self-administered questionnaire on (sexual) behaviour and risk factors for antimicrobial resistance. The proportion of the study population with ESBL-E carriage was compared by number of sexual partners using logistic regression, and across clusters of sexual behaviours with steady and casual partners, separately, using latent class analyses; all results were adjusted for recent use of antibiotics, travel and hospitalization.

RESULTS

Overall, 16.3% [95% confidence interval (CI) 13.4-19.5] of the study population tested positive for ESBL-E. The odds of ESBL-E carriage increased as number of sexual partners increased [adjusted odds ratio per ln(partner+1), 1.57, 95% CI 1.26-1.94; P<0.001]. There was no association between ESBL-E carriage and sexual behaviour with steady partner(s). Compared with participants in the 'no sex with casual partner(s)' cluster, adjusted odds of being ESBL-E positive were 2.95-fold higher (95% CI 1.52-5.80) for participants in the 'rimming and frottage' cluster (P=0.001) and 2.28-fold higher (95% CI 0.98-5.31) for participants in the 'toy use and fisting' cluster (P=0.056).

CONCLUSIONS

The prevalence of ESBL-E in MSM is higher compared with the overall Dutch population, likely due to sexual transmission with casual partners. This implies that sexually active MSM should be considered a risk group for ESBL-E carriage.

Escherichia coli Antimicrobial Susceptibility Reduction amongst HIV-Infected Individuals at the University Teaching Hospital, Lusaka, Zambia

Increased antimicrobial resistance among Human Immunodeficiency Virus (HIV)-infected individuals to commonly used antibiotics in the treatment of gastroenteritis is a public health concern, especially in resource-limited settings. We set out to compare the antimicrobial susceptibility pattern of Escherichia coli (E. coli) isolates from HIV-infected and HIV-uninfected individuals at a tertiary hospital in Lusaka, Zambia. An analytical cross-sectional study was conducted at the University Teaching Hospital from May 2019 to August 2019. Stool samples were screened, and 79 HIV-infected individuals matched by age and sex with 84 HIV-uninfected individuals that presented with E. coli associated gastroenteritis were studied. Demographics were collected from the Laboratory Information System (LIS) and stool samples were collected in a sterile leak-proof container. Samples were cultured and only those where E. coli was isolated were included in the study and tested for antimicrobial susceptibility by the Kirby-Bauer disk diffusion technique. HIV-positive individuals were 3 times (adjusted odds ratio (AOR) = 3.17; 95% CI (1.51, 6.66); p < 0.001) more likely to be resistant to quinolones compared with their HIV-negative counterparts. Similarly, HIV-positive individuals were almost 4 times (AOR = 3.97, 95% CI (1.37, 11.46); p = 0.011) more likely to have multidrug-resistant E. coli compared with those who were HIV-negative. HIV infection was associated with reduced E. coli susceptibility to commonly used antibiotics, and most cases showed resistance.

Impact of human immunodeficiency virus infection on mortality of patients who acquired healthcare associated-infection in critical care unit

To evaluate 30-day mortality in human immunodeficiency virus (HIV) and non-HIV patients who acquired a healthcare-associated infection (HAI) while in an intensive care unit (ICU), and to describe the epidemiological and microbiological features of HAI in a population with HIV.This was a retrospective cohort study that evaluated patients who acquired HAI during their stay in an Infectious Diseases ICU from July 2013 to December 2017 at a teaching hospital in Brazil.Data were obtained from hospital infection control committee reports and medical records. Statistical analysis was performed using SPSS and a multivariate model was used to evaluate risk factors associated with 30-day mortality. Epidemiological, clinical, and microbiological characteristics of HAI in HIV and non-HIV patients and 30-day mortality were also evaluated.Among 1045 patients, 77 (25 HIV, 52 non-HIV) patients acquired 106 HAI (31 HIV, 75 non-HIV patients). HIV patients were younger (45 vs 58 years, P = .002) and had more respiratory distress than non-HIV patients (60.0% vs 34.6%, P = .035). A high 30-day mortality was observed and there was no difference between groups (HIV, 52.0% vs non-HIV, 54.9%; P = .812). Ventilator-associated pneumonia (VAP) was more frequent in the HIV group compared with the non-HIV group (45.2% vs 26.7%, P = .063), with a predominance of Gram-negative organisms. Gram-positive agents were the most frequent cause of catheter associated-bloodstream infections in HIV patients. Although there was a high frequency of HAI caused by multidrug-resistant organisms (MDRO), no difference was observed between the groups (HIV, 77.8% vs non-HIV, 64.3%; P = .214). Age was the only independent factor associated with 30-day mortality (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.1, P = .017), while diabetes mellitus (OR: 3.64, 95% CI: 0.84-15.8, P = .085) and the Sequential Organ-Failure Assessment (SOFA) score (OR: 1.16, 95% CI: 0.99-1.37, P = .071) had a tendency to be associated with death.HIV infection was not associated with a higher 30-day mortality in critical care patients with a HAI. Age was the only independent risk factor associated with death. VAP was more frequent in HIV patients, probably because of the higher frequency of respiratory conditions at admission, with a predominance of Gram-negative organisms.